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General NPI Number Information
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NPI Number | 1376917591
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Entity Type | Organization
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Legal Business Name | FUNCTION & HEALTH PROFESSIONALS LLC
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Dates
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Enumeration Date | 11/27/2015
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Last Update Date | 11/27/2015
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Provider Practice Location Address
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Address Line | 685 ARLINGTON PL
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City | MACON
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State | GA
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Zip | 31201-1772
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Country | US
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Telephone | 478-292-2060
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 20731
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City | MACON
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State | GA
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Zip | 31205-0731
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Country | US
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Telephone | 478-292-2060
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Fax | 877-991-6389
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Authorized Official
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Title or Position | CEO
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Name | TIQUELLA SHANTEL KING-WHITBY
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Credential | MD, DABMA
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Telephone | 404-449-0545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | 58891
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 58891
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License Number State | GA
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